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fv1Fw l t ILL Ftt(„UHU INF-UNMAI IUN f-L' 1 <br /> ^Clxon County Pr <br /> oWam Computes No. <br /> at 1, rti <br /> 13K� 0 1 ( � ..(assigned by clerk) Lg �7 <br /> Local Como. No. Sup/Dist. Location Code Fou Aiwunl/or CuclL. Fee E x. <br /> Previous Comp. NUMBER Effective Date Other Program Activity <br /> -7S' � 7 <br /> :EE-L_�__ <br /> SITE NAME (30 characie(a) <br /> MI�V � . <br /> SITE Address (no./Pi r/Street/Suffix/Suite) Site City/State/Zi <br /> r <br /> Ld�( 5 S Z/V C <br /> 5 . <br /> PREVIOUS DBA <br /> ..Billing Blame <br /> Billing .Address (No/Dir/Street/Suffix/Suite) Billing- City/State/Zip <br /> Program ElementMI # <br /> SITE TELEPHONE NUMBER <br /> eats NKA <br /> Ft.nits <br /> 1 711 1 LJ I I I- <br /> OWNER NAME (30 characters) . <br /> OWNERAddress (No./Dir/Street/Suffix/Suite) Owner City/State/Zip <br /> SPECIAL PROGRAM INFORINATION <br /> Rec. Health <br /> No. of Service Source of Treatment Population <br /> Program Element Connections Supply Type Served <br /> Water 4 6 <br /> F-F] 1 -1 FT i <br /> San. Sup. AC SC <br /> FII... ❑ n [D IJ <br />